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General NPI Number Information
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NPI Number | 1386860898
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Entity Type | Organization
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Legal Business Name | WELLNESS CLINIC, P.C.
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Dates
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Enumeration Date | 04/17/2007
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Last Update Date | 02/15/2011
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Provider Practice Location Address
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Address Line | 5740 GETWELL RD BLDG 4C
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City | SOUTHAVEN
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State | MS
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Zip | 38672-6346
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Country | US
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Telephone | 662-892-5000
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Fax | 662-892-5002
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Provider Business Mailing Address
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Address Line | PO BOX 2024
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City | OLIVE BRANCH
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State | MS
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Zip | 38654-2209
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Country | US
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Telephone | 662-892-5000
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Fax | 662-892-5002
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Authorized Official
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Title or Position | PRESIDENT
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Name | SAVIRA V SIDHU
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Credential | M.D.
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Telephone | 662-892-5000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TP0016X
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Taxonomy Name | Prescribing (Medical) Psychologist
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License Number | MD000025744
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License Number State | TN
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